Nourishing Children Where Food is not Enough

Meeting the nutritional needs of young children is a particularly important aspect of global health, as insufficient nutrition during periods of rapid growth, which overlap with the weaning period, can have serious negative effects on health and other life-long outcomes. The long-term solution for solving micronutrient inadequacy is ensuring a sustainable and diverse diet through food-based approaches. However, because an ideal diet is not available for everyone, especially people who are poor and who live in drought-prone regions, the nutritional value of diet (i.e., food intake) must be augmented. A promising strategy for undernourished young children is to mix vitamin and mineral supplements in the form of micronutrient powders (MNPs) with food. WHO recommends providing MNPs to children ages 6–23 months in places where the prevalence of anemia is greater than 40 percent. Although the ability of MNPs to reduce anemia is well understood and documented, there are questions about whether this intervention can be scaled up at manageable costs and delivered effectively by governments in low- and middle-income countries.

SPRING staff show health workers how to use the household MNP adherence calendar, which reminds caregivers to give children MNP every other day or 3-4 times a week, as recommended.

The Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project is testing different strategies to maximize the benefits of MNPs on the health and nutrition of young children in Uganda’s Namutumba District. Part of a national pilot that began in March 2016 led by the Ministry of Health with support from World Food Program, UNICEF, and CDC, SPRING is distributing MNPs through health workers in 18 health facilities (the facility arm), and in more than 170 communities through village health teams (the community arm). SPRING is collecting quantitative, qualitative, and costing data to inform the feasibility of scaling-up these efforts in Uganda and to guide other implementers working on MNPs. SPRING will follow the implementation for seven months.

Data show that both arms made progress in the first month of programming, although the level of progress varied. SPRING and other nutrition partners are using these data to reconcile problems as they arise, which has improved programming across the district. This post details a few of the key findings from the first month of monitoring data and describes what SPRING is doing to improve MNP delivery.

Progress toward targets. The distribution targets 23,297 children in the district. So far, enrollment in the health facility arm lagged behind enrollment in the community arm: at the end of the first month, health workers in the health facility arm had enrolled 2,923 infants of a total 10,656, or 27 percent of the total target children in this arm. Village health teams (VHTs) in the community arm enrolled 6,653 children of 12,641, (53 percent of children targeted in this arm). SPRING is rolling out a plan to provide MNPs to health workers who conduct regular outreach clinics in target communities to help boost enrollment in the facility arm.

Data quality. SPRING introduced a number of tools to track MNP distribution, counseling services, exposure to MNP messages, and stock management. The first month of distribution identified difficulties with tool use, so SPRING and district officials are conducting supportive supervision visits to explain and demonstrate proper use.

Before enrolling a child into the MNP pilot program, health workers and VHTs are supposed to counsel mothers and caretakers to reinforce their knowledge of proper use and adherence to MNP consumption guidelines. Counseling fell just short of the ideal 100 percent in both arms—99 percent in the facility arm and 97 percent in the community arm—so SPRING is determining whether reports of non-counseled enrollment are a result of documentation errors.

MNP distributors track stock movement through requisition forms, dispensing logs, and stock cards, but stock monitoring data at the end of March 2016 showed that the number of MNP packets distributed was lower than the number of children enrolled in the MNP program. Although this suggests that health workers and VHTs enrolled eligible children but did give them MNPs, the more likely explanation is that there is incomplete documentation and incorrect use of stock management tools in both arms.

How communities learn about MNPs.According to data collected during enrollment in both arms of the pilot, VHTs are the most widespread source of MNP information, although health workers are an important source as well. A small percentage of community respondents reported hearing about the MNPs through SPRING-sponsored radio spots and community sensitization meetings. SPRING plans to expand communications activities in the coming months to include skits, short videos in movie halls, and radio announcements.

Enrollment errors.Both health workers and VHTs enrolled children who were above or below the eligible program age of 6–23 months. Although errors were limited—only eight admission errors in the facility and 27 in the community arm—SPRING is working with distributors and district officials to find the reasons for enrollment eligibility confusion and clarify them.

Next steps.The first month of implementation in any program presents unexpected challenges, and our results indicate progress and identify gaps that need immediate attention. The data we’ve collected provide insight into potential solutions, such as stock monitoring and enrollment errors, to these initial challenges. We anticipate that enrollment numbers in both arms will grow in the coming months. We are especially excited that the costing exercise will begin shortly. SPRING’s routine monitoring data and mid-line qualitative assessment results will inform national rollout of the MNPs. We look forward to sharing more information as the operations research progresses.

The distribution is still going on well, and by end of June a total of 15,968 children have been enrolled into the program (61% of the ultimate target). Though Facility arm (47%) is ragging behind community arm (88%), it has pulled up since the introduction of distribution of MNPs during outreach clinics. The project is now focusing on tightening the SBCC messages to encourage caretakers to get refill for those due, as well as increasing awareness in the facility arm to create demand.